Should thoracoscopic three-stage esophagectomy be performed in the prone or left lateral decubitus position?

A best evidence topic was written according to a structured protocol. The question addressed was whether the thoracoscopic phase of three-stage minimally-invasive esophagectomy is best performed in the prone or left lateral decubitus position. A total of 31 papers were found using the reported searches, of which seven represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. We conclude that there is no convincing evidence that prone thoracoscopic esophagectomy is superior to left lateral decubitus positioning. Four papers retrospectively compared the prone and lateral techniques, and while the authors suggested that the prone position was associated with better surgical ergonomics due to the effects of gravity pooling blood outside the operative view and the reduced need for lung retraction, outcomes were not significantly different. All four studies had significant limitations, such as small patient populations and sequential operating with the possible effect of a learning curve. Two studies compared respiratory and haemodynamic changes associated with prone positioning and suggest that it is physiologically well tolerated and may offer better oxygenation, similar to that seen in the prone positioning of acute respiratory distress patients. The evidence for prone thoracoscopic esophagectomy is currently not mature enough to reach any significant conclusions, and randomized studies are required.